With women making up 86 percent of its work force, it hardly seems surprising that Middletown Regional Hospital offers on-site day care as an employee benefit.

After all, many working women have young children and very few have stay-at-home husbands. Meanwhile, good day care can be expensive and hard to find.

Factor in a tight labor market for all sorts of employers and the difficulty of finding day care centers that can meet a hospital's round-the-clock needs, one might expect nearly every hospital in town to be running their own child care service.

But when Middletown Hospital launched its on-site day care center over the summer, it joined a list of employers that includes less than one third of the Tristate's hospitals and less than 10 percent of large employers in general.

We're Middletown's second-largest employer. We simply viewed this as part of what we need to do to be competitive in a tight job market, said Douglas McNeill, president and chief executive of Middletown Regional. Now, (since the center opened) we've had some of our longer-term employees say, "Where was this 25 years ago?'

Most large employers offer some form of child care-related benefit, such as flex-time, job sharing or pre-tax savings accounts that can be spent on day care. Some also arrange discount deals with local day care providers.

But very few offer on-site day care. A 1998 study by the Families and Work Institute estimates that 9 percent of employers with more than 100 workers offer on-site or near-site day care.

Most hospitals are large employers, and many rank among the biggest in their communities. And hospitals have even more reason than many large employers to offer on-site day care.

First, vast numbers of hospital employees are women, who as a group have high interest in day care services. All three large Tristate hospital systems  the Health Alliance of Greater Cincinnati, TriHealth and Mercy Health Partners  report women employees at or above 80 percent.

Second, the 24-hour, 365-day nature of hospital work demands longer hours and more flexible scheduling than many commercial day care centers provide.

Yet, of 31 acute care hospitals in Greater Cincinnati, less than one third provide on-site or near-site day care.

Middletown's new day care center is part of a $2.9 million building that houses medical offices on the upper level and child care on the lower level.

The center itself is state-of-the-art, designed to handle up to 160 children from age 6 weeks to 12 years. It offers separate rooms for different age groups equipped with age-appropriate toys and furnishings. Toilets, drinking fountains and anything else kids use is child-sized.

Many commercial day care centers require parents to pay for an entire week no matter how many days are used. Middletown Hospital's center allows flexible scheduling, including last-minute changes, and charges only for the time the child actually uses the center.

Hospitals that don't offer on-site day care say they can't afford it, can't find the space, can't hire enough day care workers or just don't want to get into the business.

When it acquired the Franciscan hospitals last year, Mercy Health Partners inherited an on-site day care that opened years ago at the former Providence Hospital. Mercy has no plans to expand the concept.

Historically, Mercy has looked at the communities near its facilities to make sure day care services were available, said spokeswoman Debbie Copeland-Bloom. In Fairfield, we decided we needed to help start a program. But (for the other Mercy hospitals in Batavia, Anderson Township, Hamilton and Western Hills) we made the decision that child care is a business unto itself.

The Health Alliance of Greater Cincinnati  one of the Tristate's five largest employers  runs University, Christ, Jewish, St. Luke and Fort Hamilton hospitals.

The Alliance has arranged discounts at several local day care centers, but does not offer on-site day care at its hospitals, said spokeswoman Mimi Smith.

We have considered it. But it does not appear to be the most important benefit issue for employees, Ms. Smith said. The biggest issue is maintaining affordable health benefits.

In Middletown, hospital officials say demand for day care has been intense for years. Of 315 employees who responded to a 1995 survey, 78 percent said they would use on-site day care.

Middletown studied its staff and found that about 60 percent of its 1,500 employees have children under 12 years old  a total of more than 600 children. In early 1999, the total licensed capacity of the nine day care centers operating in or close to Middletown was 775.

Middletown's day care isn't free to employees. Charging enough to break close to even puts fees above the least expensive in town. And those fees do not cover start-up costs.

But to hospital administrators, providing the on-site service more than justifies the costs. That's because hospitals lose a lot of productivity from child-related absenteeism and training new employees to replace those who quit to care for children.

In 1995, Middletown found that employees missed more than 6,000 hours of work due to lack of reliable child care. Cutting that rate in half would reduce sick leave expenses by about $45,000 a year.

Adding day care benefits also could reduce turnover by 15 percent. That would mean keeping about 22 people a year. With recruitment and training costs at $6,000 per worker, that's a savings of about $135,000 a year.

Meanwhile, the hospital hopes the day care will help attract hard-to-hire personnel in key specialties. The dollar value of hiring top expertise is hard to measure, but very real, Mr. McNeill said.

Tristate hospitals that offer on-site day care say they frequently operate with waiting lists because the benefit is so popular.

St. Elizabeth Medical Center runs the area's oldest on-site day care center, which opened in Covington as a volunteer service in 1967. In 1998, the day care moved to St. Elizabeth South in Edgewood, where more employees are concentrated.

Several years ago, the service was heavily subsidized and remained open through an entire second shift. Even though it recently reduced its hours to 6:30 a.m. to 8 p.m. and has increased charges, enrollment has quadrupled since the move and there's still a waiting list.

St. Elizabeth spokeswoman Karla Webb said she started using the day care nine years ago and has used it for both her children, Sam and Grace.

When I started, we were new to area. It meant so much to have your child nearby and to know that the people taking care of your child are your co-workers, Ms. Webb said.

When you have a female-based work force, it makes a lot of sense to do what you can to help them get to work, she said.

Children's Hospital has offered on-site day care for 11 years. In fact, its service has been so successful that Procter & Gamble hired the hospital to run its new employee day care, which opens this week.

The waiting list is pretty long. The joke is that when the (pregnancy test) strip turns blue, people call to get their child on the waiting list, said Rick Roche, vice president of human resources for Children's Hospital.